Healthcare Provider Details

I. General information

NPI: 1730428749
Provider Name (Legal Business Name): MARIE CROSS PUCILLO D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIE ELIZABETH CROSS D.M.D.

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 MALAGA ST
ST AUGUSTINE FL
32084-3521
US

IV. Provider business mailing address

150 MALAGA ST
ST AUGUSTINE FL
32084-3521
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-9024
  • Fax: 904-829-3546
Mailing address:
  • Phone: 904-829-9024
  • Fax: 904-829-3546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN22667
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: